Sample Threat Assessment and Management Forms



Sample Threat Assessment and Management FormsThe following pages provide sample forms to help schools document information related to all aspects of threat cases, from initial report/intake, triage, assessment, initial case management, case updates and case closure. Note that schools are NOT required to use these forms. Rather, they are provided as a resource to support schools in their efforts to identify, assess and manage potential threats to the school and its members. All the forms are also available on the DCJS website at: dcjs.virginia-center-school-and-campus-safety/threat-assessment-virginiaThe forms are available for use in a downloadable PDF format to be used as they are, or in a WORD format.School threat assessment teams are encouraged to download the forms, edit them to meet their policies and procedures, and use them as best meets their needs. Teams may use all, some, or none of these forms and may edit them to meet local needs.Overview of Threat Assessment and Management FormsPart I: Intake for Initial Report ConcernedThis form is to document initial reports. The first page is to document the incident/concern that occurred. The items about the incident are intended to gain a full understanding of what occurred and if there are any obligations for further notifications.The next two pages are to document the persons involved in the potential case, i.e., the subject(s), target(s)/others impacted, and witnesses. If necessary, use additional copies to document information about additional persons involved.Part II: TriageThis form has three pages. The first is for documenting standard record checks. Note these items should be updated to reflect the record sources and access of the school’s threat assessment team. The second page is a summary checklist of key issues for consideration of need for further assessment or intervention. The purpose of the triage is to determine if there is need for further review and action by the full team or if the concern can be reasonably resolved at triage or by referral to existing resources. The third page is for documentation of any required notifications, additional information, and the findings of the triage process.Part III: Threat AssessmentThere are two pages for this form which provides key areas for inquiry regarding each of the STEP domains, and a checklist of key factors that will inform assessment and case management considerations. The key areas and items reflect the content of the Guidelines for Threat Assessment in this Guide. This form may also be used to update key areas/information during ongoing case reviews. Part IV: Initial Case Management PlanThis form uses the STEP framework to outline the case management plan. The teams should identify tasks, team members responsible for overseeing completion of the tasks, and a date/time the task is due for update to the team.Part V: Case UpdateLike the initial Case Management form, this uses the STEP framework for modification to the case management plan, including both updates such as new information or outcomes of prior action items, and new or ongoing tasks for each of the domains. The teams should identify tasks, team members responsible for overseeing completion of the tasks, and a date/time the task is due for update to the team. This form can be used to document each review of the case.Part V: Case ClosureTeams may use this form to document a thorough, diligent and deliberate review of the case to ensure that any concerns using the STEP framework have been sufficiently addressed, to the point that the case is stable at a Routine/No Known Concern or Low Level of Concern.THREAT ASSESSMENT & MANAGEMENT FORMPART I: INTAKE for INITIAL REPORT OF CONCERNDate Reported: FORMTEXT ?????Day of Week:? Monday ? Tuesday? Wednesday? Thursday? Friday ? Saturday? SundayTime: FORMTEXT ?????? AM ? PMTaken by: FORMTEXT ?????School: FORMTEXT ?????Position: FORMTEXT ?????REPORTING PARTY:Name: FORMTEXT ?????? UnknownID #: FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other:_______________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade:__________(if student)School: FORMTEXT ?????Building/Program: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????INCIDENT:Date Occurred: FORMTEXT ?????Day of Week:? Monday ? Tuesday? Wednesday? Thursday? Friday ? Saturday? SundayTime: FORMTEXT ?????? AM ? PMLocation:? School Property [? In School Building ? School Grounds] ? School Bus ? School Sponsored Activity ? Other: FORMTEXT ?????School: FORMTEXT ?????Building/Program: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ConcernTypes:? Harm to Others ? Abduction? Stalking ? Bullying ? Suicidal/Self-Harm ? Aberrant Communication/Behavior? Assault [? Physical ? Sexual)? Bomb/Arson ? Weapon? Harassment? Mental Health ? Disruptive / Suspicious BehaviorNature:? Act ? Threat ? Concern Modes: ? In Person ? Phone ? Text ? Email ? Letter ? Social Media ? Internet ? Other : FORMTEXT ?????Persons(s) injured: ? Yes ? No ? Unknown Persons(s) require medical attention? ? Yes ? No ? Unknown Weapon involved: ? Yes ? No ? Unknown Type of Weapon: ? Firearm[? Rifle/Shotgun ? Pistol] ? Edged ? Explosive ? Other: FORMTEXT ?????Weapon referenced: ? Yes ? No ? Unknown Type of Weapon: ? Firearm[? Rifle/Shotgun ? Pistol] ? Edged ? Explosive ? Other: FORMTEXT ?????Law Enforcement Involved: ? Yes ? No ? Unknown Agency: FORMTEXT ?????Arrest/Custody of Subject: ? Yes ? No ? Unknown Details of the incident/nature of concerns. Note what occurred, who was involved, where and when, if others were impacted or harmed, etc.If threats/concerning statements were communicated, provide direct quotes where possible, using quotation marks to indicate direct quotes. Attach original communications if available. FORMTEXT ?????-10096512384405Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsPART I: INTAKE for INITIAL REPORT OF CONCERN – PERSONS INVOLVEDSUBJECT (1) Engaging in threatening, aberrant or concerning behavior:Name: FORMTEXT ?????? UnknownID #: FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Target: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????SUBJECT (2) Engaging in threatening, aberrant or concerning behavior:Name: FORMTEXT ?????? Unknown FORMTEXT ????? FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Target: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????Note: If more than two subjects of concern in this incident, attach additional copies of this page with subject’s information.TARGET (1):Name: FORMTEXT ?????? Unknown FORMTEXT ????? FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Subject: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????TARGET (2):Name: FORMTEXT ?????? Unknown FORMTEXT ????? FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Subject: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????Note: If more than two targets in this incident, attach additional copies of this page with target’s information.-1022358726170Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsPART I: INTAKE for INITIAL REPORT OF CONCERN – PERSONS INVOLVEDWitness (1):Name: FORMTEXT ?????? Unknown FORMTEXT ????? FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Subject: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????Witness Interview FORMTEXT ?????Witness (2):Name: FORMTEXT ?????? Unknown FORMTEXT ????? FORMTEXT ?????Affiliation:? Administrator ? Teacher ? Staff ? Student ? Parent/Guardian ? Contractor ? Other: FORMTEXT ?????____________________________ ? None/UnknownStatus:? Current ? Former ? ProspectiveGrade: FORMTEXT ?????_________(if student)School: FORMTEXT ????? Relationship to Subject: FORMTEXT ?????EmergencyContact: FORMTEXT ?????Relationship:? Parent ? Spouse/Partner ? Guardian? Other: FORMTEXT ?????Home Address: FORMTEXT ?????Phone: FORMTEXT ?????Witness Interview FORMTEXT ?????Note: If more than two witnesses in this incident, attach additional copies of this page.Regarding: FORMTEXT ?????Case: FORMTEXT ?????PART II: TRIAGE – RECORDS CHECKS RECORDS CHECKS (ALL):CheckedNS=Not Significant NA=Not ApplicableNotes about Significant findings:Photo? Yes ? NS/NA FORMTEXT ?????Threat Assessment Team history? Yes ? NS/NA FORMTEXT ?????Criminal history? Yes ? NS/NA FORMTEXT ?????Driver license information? Yes ? NS/NA FORMTEXT ?????Vehicle/Parking information? Yes ? NS/NA FORMTEXT ?????SRO/SSO contacts? Yes ? NS/NA FORMTEXT ?????Local Law Enforcement contacts? Yes ? NS/NA FORMTEXT ?????Other Law Enforcement contacts? Yes ? NS/NA FORMTEXT ?????Protective/No Contact Orders? Yes ? NS/NA FORMTEXT ?????No Trespass Notice? Yes ? NS/NA FORMTEXT ?????Concealed weapons permit? Yes ? NS/NA FORMTEXT ?????Weapons purchase permit? Yes ? NS/NA FORMTEXT ?????Social media? Yes ? NS/NA FORMTEXT ?????Online Search? Yes ? NS/NA FORMTEXT ?????Other:? Yes ? NS/NA FORMTEXT ?????RECORDS CHECKS: School StaffDisciplinary actions ? Yes ? NS/NA FORMTEXT ?????Grievances filed? Yes ? NS/NA FORMTEXT ?????Title IX actions? Yes ? NS/NA FORMTEXT ?????Application ? Yes ? NS/NA FORMTEXT ?????Other:? Yes ? NS/NA FORMTEXT ?????RECORDS CHECKS: StudentsClass schedule? Yes ? NS/NA FORMTEXT ?????Academic standing/progress? Yes ? NS/NA FORMTEXT ?????IEP/504? Yes ? NS/NA FORMTEXT ?????Transfer records? Yes ? NS/NA FORMTEXT ?????Conduct/Discipline? Yes ? NS/NA FORMTEXT ?????Title IX actions? Yes ? NS/NA FORMTEXT ?????Other:? Yes ? NS/NA FORMTEXT ?????OTHER RECORDS CHECKS: FORMTEXT ?????Note: Complete a record check form for each subject and target.-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????PART II: TRIAGE INQUIRY SUMMARY SHEETSUBJECT Notes:Behavior(s) causing concern/impacting others? Yes ? No ? Unknown FORMTEXT ?????Concerning or Aberrant Communications? Yes ? No ? Unknown FORMTEXT ?????Directly communicated threats? Yes ? No ? Unknown FORMTEXT ?????Leakage: grievances, ideation/intent, planning, preparations, targets? Yes ? No ? Unknown FORMTEXT ?????Identified grievances/motives for violence? Yes ? No ? Unknown FORMTEXT ?????Fixation on grievances, targets, violent resolution, etc.? Yes ? No ? Unknown FORMTEXT ?????Interest or Identification with perpetrators, grievances, or violent acts? Yes ? No ? Unknown FORMTEXT ?????History of violence or novel aggression? Yes ? No ? Unknown FORMTEXT ?????Last resort behaviors: Desperation, imperative, diminished alternatives? Yes ? No ? Unknown FORMTEXT ?????Pathway behaviors – Planning ? Yes ? No ? Unknown FORMTEXT ?????Pathway behaviors – Preparing: means, methods, opportunity, proximity ? Yes ? No ? Unknown FORMTEXT ?????Stalking/unwanted contact, communication, or pursuit? Yes ? No ? Unknown FORMTEXT ?????Energy bursts/changes in pattern(s) of disruptive/concerning behavior(s)? Yes ? No ? Unknown FORMTEXT ?????Last Resort behaviors/JACA? Yes ? No ? Unknown FORMTEXT ?????Despondency, despair, isolation, and/or suicidality? Yes ? No ? Unknown FORMTEXT ?????Significant cognitive, emotional, or psychological concerns? Yes ? No ? Unknown FORMTEXT ?????Significant or multiple stressors/difficulty coping? Yes ? No ? Unknown FORMTEXT ?????Lack of inhibitors/stabilizers to prevent violence? Yes ? No ? Unknown FORMTEXT ?????Other: FORMTEXT ?????? Yes ? No ? Unknown FORMTEXT ?????Comments: FORMTEXT ?????TARGET / OTHERS NotesIdentified targets (person/proxy, place, program, process, philosophy)? Yes ? No ? Unknown FORMTEXT ?????Fearful of harm? Yes ? No ? Unknown FORMTEXT ?????Protective actions/responding as if subject poses a safety concern? Yes ? No ? Unknown FORMTEXT ?????Vulnerability: e.g., consistent routine, low situational awareness? Yes ? No ? Unknown FORMTEXT ?????Need for assistance? Yes ? No ? Unknown FORMTEXT ?????Other: FORMTEXT ?????? Yes ? No ? Unknown FORMTEXT ?????Comments: FORMTEXT ?????ENVIRONMENTNotesOrganizational climate concerns: e.g., bullying, bias, poor conflict mgmt.? Yes ? No ? Unknown FORMTEXT ?????Systemic/procedural? Yes ? No ? Unknown FORMTEXT ?????Report latency/failure? Yes ? No ? Unknown FORMTEXT ?????Bullying/bias? Yes ? No ? Unknown FORMTEXT ?????Lack of support, guidance, or resources? Yes ? No ? Unknown FORMTEXT ?????Adverse social influences? Yes ? No ? Unknown FORMTEXT ?????High rates of violence, harassment, disruption, stress? Yes ? No ? Unknown FORMTEXT ?????Disproportionate rate/severity of concerns? Yes ? No ? Unknown FORMTEXT ?????Other: FORMTEXT ?????? Yes ? No ? Unknown FORMTEXT ?????Comments: FORMTEXT ????? PRECIPITATING EVENTSNotesImpending loss, failure? Yes ? No ? Unknown FORMTEXT ?????Key dates/events ? Yes ? No ? Unknown FORMTEXT ?????Triggers/reminders? Yes ? No ? Unknown FORMTEXT ?????Views intervention negatively? Yes ? No ? Unknown FORMTEXT ?????Contagion influence? Yes ? No ? Unknown FORMTEXT ?????Return from separation? Yes ? No ? Unknown FORMTEXT ?????Other: FORMTEXT ?????? Yes ? No ? Unknown FORMTEXT ?????Comments: FORMTEXT ?????-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????NOTIFICATIONSReasonNotes? Superintendent/Designee? Student poses High/Imminent threat to self/others ? Other FORMTEXT ?????? Principal ? High/imminent threat ? Crime ? Other FORMTEXT ?????? Law Enforcement? High/imminent threat ? Crime ? Other FORMTEXT ?????? Parent/Guardian? Student poses High/Imminent threat to self/others ? Other FORMTEXT ?????? Other: FORMTEXT ?????? Yes ? No FORMTEXT ?????? Other: FORMTEXT ?????? Yes ? No FORMTEXT ?????NOTES: FORMTEXT ?????CASE PRIORITY LEVEL:? Critical/Imminent? High? Moderate? Low? Routine/NoneTRIAGE RECOMMENDATION:BTAM CASE #? No identified Concerns:Close case? Non-TAT Concerns:Referral(s)? Unknown/On-going Threat:Initiate TAT Case FORMTEXT ?????TRIAGE COMPLETED BY: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????PART III: THREAT ASSESSMENT KEY AREAS FOR INQUIRYSUBJECT Key Areas for InquiryKey FactorsIs subject engaging in behaviors causing concern? ? Yes ? No ? Unknown Concerns about nature, pattern, context, or change in frequency or intensity? ? Yes ? No ? Unknown ? Others significantly impacted? Patterned occurrence continues? Changes in behavior/patternIs subject engaging in concerning, aberrant & threatening communications? ? Yes ? No ? Unknown Indicating grievances, ideation, intent, planning, preparation, or targets? ? Yes ? No ? Unknown ? Directly Communicated Threats? Leakage? Multiple communication modes? Intent to engage in violence ? Warning othersSubject expressed motives and/or grievances with intended violence/harm? ? Yes ? No ? Unknown ? ImmersionFixation?? Grievances? Targets/sources? ViolenceHas the subject shown inappropriate interest in violence? ? Yes ? No ? Unknown Identification?? Incidents or perpetrators ? Grievances of perpetrators? Weapons/tactics ? Notoriety or fame ? Violent IdeologyDoes subject have (or developing) the capacity to engage in violence? ? Yes ? No ? Unknown ? Violence Hx ? Novel Aggression? Pathway behaviors?? Planning & research ? Preparations ? Surveillance, stalking, rehearsal? Energy Burst behaviors? Rapid Escalation/ImminenceSubject experiencing/expressing hopelessness, desperation, and/or despair? ? Yes ? No ? Unknown ? Last resort behaviors? JACA behaviors?? Justification ? Alternatives (lack of) ? Consequences ? Martyrdom ? Ability ? Legacy tokenSubject’s behavior indicates need for intervention/support services? -1657351609725Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools ? Yes ? No ? Unknown ? Depressed mood? Hallucinations? Delusions? Extreme wariness/distrust? Martyrdom ? Pervasive maladaptive behavior ? Untreated symptoms of MI? Poor treatment complianceDoes subject have protective factors or stabilizers that inhibit violence? ? Yes ? No ? Unknown Subject has positive, trusting, sustained relationship with positive figure? ? Yes ? No ? Unknown Views violence as unacceptable, immoral: ? Yes ? No ? Unknown Accepts responsibility for actions: ? Yes ? No ? Unknown Demonstrates remorse for inappropriate behavior: ? Yes ? No ? Unknown Respects reasonable limits and expectations: ? Yes ? No ? Unknown Uses socially sanctioned means of addressing grievances: ? Yes ? No ? Unknown Values life, job, relationships, freedom: ? Yes ? No ? Unknown Fears loss of reputation, job, freedom, life: ? Yes ? No ? Unknown Maintains, uses, and builds effective coping skills: ? Yes ? No ? Unknown Treatment access, compliance, engagement: ? Yes ? No ? Unknown ? Few/no protective factors? Protective failures diminishing? Loss of key supportSubject: FORMTEXT ?????Case: FORMTEXT ?????TARGET Key Areas for InquiryKey FactorsAre targets vulnerable, concerned, or impacted by subject’s behavior? ? Yes ? No ? Unknown ? Significant impact/fear? Significant impart/fear? Availability, access, proximity? Vulnerability? Few protective/coping skills? Need for assistanceENVIRONMENTAL/SYSTEMIC Key Areas for InquiryAre there Environmental/Systemic factors that are impacting the situation? ? Yes ? No ? Unknown ? School climate: bullying, bias? Systemic/procedural? Report latency/failure? Poor Conflict management ? Unfair treatment? Inadequate resources? Adverse influencesPRECIPITATING EVENTS Key Areas for InquiryAre there Precipitating Events that may impact situation? ? Yes ? No ? Unknown ? Impending loss, failure, injustice? Key dates/events? Triggers/reminders? Views intervention as injustice? Contagion influence? Return from separationPROCESS INTEGRITY Key Areas for InquiryAre there concerns with consistency, credibility, or bias in information? ? Yes ? No ? Unknown ? Poor credibility of subject? Poor credibility of sources? Inconsistency between sources? Significant gaps/unknownsOther Relevant Information: FORMTEXT ?????-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsCURRENT CASE PRIORITY LEVEL:? Critical/Imminent? High? Moderate? Low? Routine / NoneCase Status:? No identified Concerns: Close case? Non-TAT Concerns: Referral(s)? On-going Threat: Sustain TAT CaseREFERRALS: FORMTEXT ?????ASSESSMENT COMPLETED BY: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????PART IV: INITIAL CASE MANAGEMENT PLANINTERVENTION/TASKRESPONSIBLE PERSONDATE DUESubject Interventions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Target Interventions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Environment Interventions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INTERVENTION/TASKRESPONSIBLE PERSONDATE DUEPrecipitating Events (Monitoring/Interventions) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date for Next Review: FORMTEXT ?????Print name of Team Leader: FORMTEXT ?????Date: FORMTEXT ?????Signature of Team Leader: FORMTEXT ?????-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????PART V: CASE UPDATE (to be updated regularly while case is active)INTERVENTION/TASKSubjectUpdates:Source FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????InterventionsResponsible PersonDUE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Target InterventionsUpdates:Source FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????InterventionsResponsible PersonDue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Environment InterventionsUpdates:Source FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????InterventionsResponsible PersonDue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????Precipitating Events (Monitoring/Interventions)Updates:Source FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????InterventionsResponsible PersonDue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Comments FORMTEXT ?????CURRENT CASE PRIORITY LEVEL:? Critical/Imminent? High? Moderate? Low? Routine / NoneCase Status:Date for Review:? No identified Concerns: Close case? Non-TAT Concerns: Referral(s)? On-going Threat: Sustain TAT Case FORMTEXT ?????REFERRALS: FORMTEXT ?????Update COMPLETED BY: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public SchoolsSubject: FORMTEXT ?????Case: FORMTEXT ?????PART VI: CASE CLOSURE? The Threat Assessment Team has completed necessary interventions and actions regarding this case. ? The Level of Concern for this case is currently Routine/None or Low. ? If at a Low Level of Concern, remaining issues or tasks are being adequately addressed and monitored by relevant resources within the school or community at this time. ? Any relevant referrals have been made and those resources are engaged as needed. ? The full Threat Assessment Team has reviewed and concurred with all the following regarding the domains of assessment and intervention:SUBJECT: The subject is not known to be engaging in any behaviors that:? Is posing a threat of violence, harm, or significant disruption to self or others, or? May reasonably pose a threat of violence, harm, or significant disruption to self or others, or? Indicate a need for assistance or intervention.TARGET/Others: Targets or others are not known to:? Have any significant ongoing concerns regarding their safety regarding this case? Be engaging in any behaviors that place them at risk regarding this case? Have any significant ongoing or further need for assistance or intervention.ENVIRONMENT/SYSTEMIC CONCERNS: There are no known:? Environmental / systemic concerns significantly impacting this case currently.? Environmental / systemic concerns that are reasonably likely to occur that would significantly impact upon this case, ORPRECIPITATING EVENTS: There are no known:? Precipitating Events that are significantly impacting this case currently.? Precipitating Events that are reasonably likely to occur that would significantly impact upon this case. THERE ARE NO FURTHER IDENTIFIABLE ACTION STEPS. THIS CASE HAS BEEN RESOLVED AND IS CLOSED FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????NamePositionSignatureDate-254009293225Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools00Threat Assessment and Management Case Form — ? Deisinger (2019); Licensed to Virginia Public Schools ................
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